Can Combining Therapies Have a Synergistic Effect?

Maples is a faculty specialist in the department of psychiatry at the University of Texas Health Science Center (UTHSCSA). Her area of concentration is on the implementation of psychosocial treatments and liaising with community mental health clinics and government agencies. She has worked to adapt psychosocial treatments to special populations for over a decade.

Natalie Maples, Dawn Velligian, Ph.D., the pioneer in cognitive adaptation training, and David Roberts, Ph.D., whose work has focused on the development and testing of social cognition and interaction training (SCIT), will be presenting at the NAMI National Convention on June 29, 2013.

NAMI: What is Multimodal Cognitive Treatment (Mcog)?

Maples: Multimodal cognitive treatment (Mcog) is a multimodal treatment program designed for persons with schizophrenia. It is a combined treatment of two other therapies. The first half of the therapy is cognitive adaptation training, or CAT, which has been shown in eight research trials to be effective at improving someone’s daily tasks such as filling out medication containers, keeping up with hygiene, or getting a job. The treatment is done in the home once a week over a 9-month or a one year period. The other half of Mcog is cognitive behavioral therapy for psychosis (CBTp) that targets specific psychotic symptoms, including delusions and hallucinations. CBTp was created in the U.K. and the Mcog trial is the first in the U.S. that has tested CBT for psychosis. It is typically used in conjunction with psychotropic medications, to help people with psychosis experiencing persistent positive symptoms. Mcog utilizes a combination of CAT to improve medication adherence and functional outcome and CBT for psychosis targets decreasing positive symptoms such as hallucinations and delusions and their associated distress. The combination of the two treatments is an interesting model because in one sense the therapist plays a traditional role but is also helping someone with everyday tasks such as improving their hygiene or getting a job.

NAMI: How does it help people with schizophrenia?

Maples: That’s what we are investigating right now. Our trial is a five-year research study funded from the NIMH [National Institute of Mental Health]. It will be ending in the next several months, and then we will analyze and publish the data. The idea is that CAT helps people with functional problems, by improving their tasks of daily living and also in their quality of life. CBT for psychoses helps people reduce the positive symptoms of schizophrenia, i.e., hallucinations and delusions. What we are looking at is whether or not Mcog, the combination of the two treatments, can do even more. If the synergetic effect of the two therapies is positive, then there would be even more of an effect than one of the treatments by itself.

NAMI: What is involved with the treatment? Can you give us an example?

Maples: When we first see someone for Mcog treatment, we complete what is called a treatment planning form. We match, or individualize, the treatment to the specific patient. The treatment planning is based on the client’s level of executive function and everyday behaviors. In addition, we do neurocognitive tests prior to the client being randomized in order to complete the treatment planning form. The rest is based on the clinical interviews with the client and doing an environmental assessment in their homes. We want to know what could be interfering with them being the most productive. What are they doing every day? And how do they organize belongings?

NAMI: What it’s one distinguishable feature that differs Mcog from other psychosocial treatments?

Maples: One of the biggest differences is that the treatment is completed in the home. Our treatment plan is also based on what is causing the most impairment. In addition to doing a computerized cognitive test battery of attention and memory, we are also talking to the client about what they feel is causing the most impairment and backing that up with the environmental assessment. The advantage of going into their homes is that we can see how they are living their lives. For example, do they even have the hygiene supplies they need to complete their daily hygiene needs? Another difference is that we have the funds to provide clients with necessary items. For example, if we are working on helping a client find a job, but they don’t have appropriate clothing then we have the funding to purchase the item they need, which in return would help with moving the treatment along.

NAMI: Does the therapeutic intervention improve the evolution of the illness and the quality of life of people with schizophrenia?

Maples: That is the goal of the trial, but we don’t have the support to say so right now. CAT, independently, has been shown to improve quality of life and we would hope that would transfer over to the combined multimodal treatment. CBT has been shown to improve the evolution of the illness. For a long time, therapists and health professionals thought that the schizophrenia population was not appropriate for this type of therapy. However, studies have shown that cognitive behavior therapy can be used and applied to psychotic symptoms to help decrease not just the experience of them, but the distress experienced because of those psychotic symptoms. So it’s not just dependence on medication. Although we advocate for medication, this population is appropriate for therapy as well.

NAMI: How much empirical support is available for these treatments?

Maples: There is currently no empirical support for Mcog, the combined treatment, since we are still in the trial phase. However, there is much empirical support for both CAT and CBT for psychosis separately. There have been many articles written and published for each treatment independently.\

NAMI: Is the Mcog model transferable to other mental illnesses?

Maples: We don’t know since the trial isn’t done yet. However, we have used CAT and others have used CBT for psychosis on different populations, so we think, by extension, Mcog could also be helpful for other diagnoses.